Horizon Home Care & Hospice LogoThe Hospital Discharge Care Program is a collaborative program between Froedtert Hospital and Horizon Home Care that helps patients at very high risk for readmission to the hospital. This program will help you with your care after discharge from the hospital for approximately 30 days until your health is stable enough to resume usual care with your primary care provider. We aim to:
  • Help you (and your family) to create a plan of care that meets your personal goals and needs.
  • Help you identify and coordinate resources such as home care nursing, social work, therapy and specialty services while remaining in your home.
  • Identify and address medical needs as they occur.
  • Coordinate the transfer of you and your plan of care to your primary care provider for follow-up and continuing care of your condition.

During Your Hospital Stay

The Hospital Discharge Care team will be informed of your health condition and health care needs while you are in the hospital and what you will need at home. Your primary care physician will be contacted before you can be enrolled in the program. The inpatient care team will make your first appointment with the Horizon Home Care nurse. This appointment will take place in your home. The inpatient care team works together to make goals for your care at home.

After You Leave the Hospital

We will use both virtual (electronic) and in-person health care services to care for you. Horizon Health Care will provide a laptop for virtual visits, and you will have a Horizon Home Care nurse at home with you to help with your care. Here is what you can expect.

  • Day 1 — The Horizon Home Care nurse will come to your home for the first visit.
  • Within 3 days — You will have your first virtual visit with the home care nurse and the Hospital Discharge Care team.
  • Weekly — You will have at least one virtual visit a week with your care team. You may need to be seen in the clinic at Froedtert Hospital if your care team feels this is necessary for your health.
  • After 4-6 weeks — Your care will be transferred to your primary care provider for your usual follow-up care and treatment.

Your Care Team

This care team works under the direct supervision of a physician.

  • Nurse (RN) inpatient case manager — Gets approval for you to be in the program, makes your first appointment and communicates your current condition and health care needs to the nurse care coordinator.
  • Advanced practice provider (APP) — Assesses your health during virtual visits, helps create your care plan, provides care and communicates with your care team.
  • Nurse care coordinator — Enrolls you in the program, schedules your virtual visits and facilitates virtual visits.
  • Pharmacist — Works with the advanced practice provider to monitor all of your medications, provides education on your medications and answers any medication-related questions.
  • Medical assistant/scheduler — Keeps track of information needed for program success, contacts you for appointment reminders and provides follow-up information on your care.
  • Horizon Home Care nurse — Helps with your medical needs in real time and is available after hours and on weekends to meet your needs.

Contact Us

Horizon Home Care will be your primary contact with any questions you or your family have regarding your care. Horizon will contact the Hospital Discharge Care Program if your question/concern requires additional assessment.

Contact Horizon Home Care at 414-365-8300.

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